Citation Nr: 1020559
Decision Date: 06/04/10 Archive Date: 06/10/10
DOCKET NO. 06-16 156 ) DATE
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On appeal from the
Department of Veterans Affairs Regional Office in Winston-
Salem, North Carolina
THE ISSUE
Entitlement to service connection for an acquired psychiatric
disorder, claimed as post-traumatic stress disorder (PTSD)
and to include a bipolar disorder.
ATTORNEY FOR THE BOARD
J. L. Prichard, Counsel
INTRODUCTION
The Veteran had active service from September 1961 to
February 1984.
This matter comes before the Board of Veterans' Appeals
(Board) on appeal of a January 2005 rating decision of the
Winston-Salem, North Carolina, Regional Office (RO).
The Veteran cancelled his appointment of The American Legion
as his representative in a May 2010 Statement in Support of
Claim. He now represents himself in this appeal.
The appeal is REMANDED to the RO via the Appeals Management
Center (AMC), in Washington, DC. VA will notify the Veteran
if further action is required.
REMAND
The Veteran contends that he has developed PTSD as a result
of active service. He notes that a private doctor has
diagnosed him with this disability.
The record indicates that the Veteran had over 22 years of
active military service. His awards and decorations include
The Purple Heart and The Combat Infantryman's Badge.
Therefore, his exposure to combat stressors is conceded.
The Veteran told the August 2004 private examiner that he was
hospitalized for a psychiatric disability during active
service. He also said that on another occasion he
experienced psychiatric symptoms that led to a psychiatric
evaluation during service.
Unfortunately, it appears that only a single page of the
Veteran's service treatment records have been obtained. The
Board finds that another attempt should be made to obtain the
Veteran's service treatment records from any possible source
at which they may be maintained. This should include
requesting that the Veteran identify any facility at which he
was hospitalized during service, and then contacting that
facility directly. All attempts to obtain records from each
potential source should be documented in the claims folder,
to include negative responses. A separate search by the
National Personnel Records Center (NPRC) for hospital records
should also be conducted.
In addition, an attempt should be made to obtain the
Veteran's personnel records in the hope that they might be
probative to the appeal.
The record shows that the Veteran began to receive treatment
for a bipolar disorder in 1995. Treatment records dating
from 1995 to 2004 have been obtained from various private
sources. These show continued treatment for a bipolar
disorder but do not mention PTSD or the Veteran's Vietnam
experiences.
The Veteran was afforded a VA psychological examination in
July 2004. This examiner did not reach a diagnosis of PTSD,
but instead made a diagnosis of a bipolar disorder.
Unfortunately, she did not provide an opinion as to whether
or not the bipolar disorder was related to active service.
Furthermore, it does not appear that the Veteran underwent
standardized psychological testing that would tend to
indicate whether or not he has PTSD.
It is noted that all psychiatric disorders that are diagnosed
have to be considered in this claim according to recent
guidance of the United States Court of Appeals for Veterans
Claims (Court). See Clemons v. Shineski, 23 Vet. App. 1
(2009).
The initial diagnosis of PTSD was made by the August 2004
private doctor. This doctor has seen the Veteran on two
occasions since August 2004, both approximately one year
apart, and has continued to find PTSD. While the examination
reports contain references to the Veteran's experiences in
Vietnam and to symptoms such as nightmares and flashbacks
from his Vietnam service, the examiner did not expressly
relate the PTSD to combat, nor discuss the potential impact
that other experiences such as the death of the Veteran's
first wife may have had on the development of his PTSD.
In view of these matters, the Board believes that additional
development is required to determine which, if any,
psychiatric disability the Veteran may have developed as a
result of active service.
Accordingly, the case is REMANDED for the following action:
1. Make another attempt to obtain the
Veteran's service treatment records.
The NPRC should be contacted as should
his Reserve unit as appropriate. Any
other appropriate organization should
also be contacted. If the appellant
has any service treatment records he
should provide them to the VA. This
development should include a request to
the Veteran to provide the name of the
facility at which he was hospitalized
for a psychiatric disability during
active service. The NPRC should check
for records of any hospitalization that
the Veteran reports. An attempt should
also be made to obtain the Veteran's
service personnel records. Document
all record requests to include the
names and replies from each entity that
is contacted.
2. Obtain the names and addresses of all
medical care providers who have treated
the Veteran for his psychiatric
disability since 2004. After securing
the necessary release, obtain these
records and associate them with the
claims folder. Any negative reply should
also be placed in the claims folder.
3. After the records requested above
have been obtained or it has been
documented that they are unobtainable,
schedule the Veteran for an additional VA
psychiatric/psychological examination to
determine the nature and severity of all
current psychiatric disabilities. The
claims folder MUST be provided to the
examiner for use in the study of this
case, and the examiner should indicate in
their report that it has been reviewed.
All indicated tests and studies should be
conducted. This should include
standardized testing that would tend to
show whether or not the Veteran currently
has PTSD as a result of Vietnam combat or
other stressors during active service.
After the completion of the record
review, testing, and examination, the
examiner should attempt to express the
following opinions:
a) Does the Veteran currently have a
chronic psychiatric disability?
b) If the Veteran currently has a chronic
psychiatric disability, what is the
diagnosis or diagnoses of that
disability?
c) For each disability that may be
diagnosed on the examination, please
attempt to opine whether it is as likely
as not (50 percent probability or higher)
that it is related to the Veteran's
active service. If there is a current
diagnosis of PTSD, is this the result of
active service or the result of other
post service stressors?
The reasons and bases for all opinions
should be provided in full.
4. After the development requested above
has been completed to the extent
possible, the RO should again review the
record. If any benefit sought on appeal,
for which a notice of disagreement has
been filed, remains denied, the Veteran
should be furnished a supplemental
statement of the case and given the
opportunity to respond thereto.
Thereafter, the case should be returned to the Board, if in
order. The Board intimates no opinion as to the ultimate
outcome of this case. The Veteran need take no action until
otherwise notified.
The Veteran has the right to submit additional evidence and
argument on the matter or matters the Board has remanded.
Kutscherousky v. West, 12 Vet. App. 369 (1999).
This claim must be afforded expeditious treatment. The law
requires that all claims that are remanded by the Board of
Veterans' Appeals or by the United States Court of Appeals
for Veterans Claims for additional development or other
appropriate action must be handled in an expeditious manner.
See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2009).
_________________________________________________
MICHAEL D. LYON
Veterans Law Judge, Board of Veterans' Appeals
Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the
Board of Veterans' Appeals is appealable to the United States
Court of Appeals for Veterans Claims. This remand is in the
nature of a preliminary order and does not constitute a
decision of the Board on the merits of your appeal.
38 C.F.R. § 20.1100(b) (2009).